Conservative femoral revision using short cementless stems with a tapered rectangular shape for selected Paprosky II-IV bone defects: an average seven-year follow-up.

BACKGROUND: The use of long stems for severe femoral bone defects is suggested by many scholars, but it is associated with further bone loss, intraoperative fracture, increased surgical trauma, and complications. With better bone retention, simple and quick surgical procedures, and minimal complications, the short cementless stems with a tapered rectangular shape may be an alternative for femoral revision. This study aimed to evaluate the results of this type of stem in treating selected Paprosky II-IV bone defects. METHODS: This retrospective study included 73 patients (76 hips involved) who underwent conservative femoral revision using the short cementless stems with a tapered rectangular shape between January 2012 and December 2020. The preoperative femoral bone defects were identified as follows: 54 cases of type II, 11 cases of type IIIA, 7 cases of type IIIB, and 4 cases of type IV. Indications for revision included aseptic loosening (76.3%) and prosthetic joint infection (23.7%). Six cementless stems with a tapered rectangular shape from three companies were used in all patients. Among them, SLR-Plus, SL-Plus MIA, and Corail stems were employed in most patients (40.8%, 23.7%, and 17.1%, respectively). The average length of these stems measured 171.7 mm (SD 27 mm; 122-215 mm). Radiographic results, Harris hip scores (HHS), complications, and survivorship were analyzed. The follow-up lasted for 7 years on average (range 3-11 years). RESULTS: The subsidence was observed in three hips (3.9%), and all stems achieved stable bone ingrowth. Proximal femoral bone restoration in the residual osteolytic area was found in 67 hips (88.2%), constant defects in nine hips (11.8%), and increasing defects in 0 cases. There was no evidence of stem fractures and stem loosening in this series. The mean HHS significantly improved from 32 (range 15-50) preoperatively to 82 (range 68-94) at the last follow-up (t = - 36.297, P < 0.001). Five hips developed prosthesis-related complications, including three infection and two dislocation cases. The mean 5- and 10-year revision-free survivorships for any revision or removal of an implant and reoperation for any reason were 94.6% and 93.3%, respectively. Both mean 5- and 10-year revision-free survivorships for aseptic femoral loosening were 100%. CONCLUSION: Conservative femoral revision using short cementless stems with a tapered rectangular shape can provide favorable radiographic outcomes, joint function, and mid-term survivorship with minimal complications. Of note, a sclerotic proximal femoral bone shell with continued and intact structure and enough support strength is the indication for using these stems.

One-stage revision using intra-articular carbapenem infusion effectively treats chronic periprosthetic joint infection caused by Gram-negative organisms.

Gram-negative periprosthetic joint infection (PJI) has been poorly studied despite its rapidly increasing incidence. Treatment with one-stage revision using intra-articular (IA) infusion of antibiotics may offer a reasonable alternative with a distinct advantage of providing a means of delivering the drug in high concentrations. Carbapenems are regarded as the last line of defense against severe Gram-negative or polymicrobial infection. This study presents the results of one-stage revision using intra-articular carbapenem infusion for treating Gram-negative PJI, and analyzes the characteristics of bacteria distribution and drug sensitivity. We retrospectively reviewed 32 patients (22 hips and 11 knees) who underwent single-stage revision combined with IA carbapenem infusion between November 2013 and March 2020. The IA and intravenous (IV) carbapenem infusions were administered for a single Gram-negative infection, and IV vancomycin combined with IA carbapenems and vancomycin was applied for polymicrobial infection including Gram-negative bacteria. The bacterial community distribution, drug sensitivity, infection control rate, functional recovery, and complications were evaluated. Reinfection or death caused by PJI was regarded as a treatment failure. Gram-negative PJI was mainly caused by Escherichia coli (8/34), Enterobacter cloacae (7/34), and Klebsiella pneumoniae (5/34). Seven cases (7/32) involved polymicrobial PJIs. The resistance rates of penicillin, cephalosporin, quinolones, and sulfonamides were > 10%, and all penicillin and partial cephalosporins (first and second generation) were > 30%. Of 32 cases, treatment failed to eradicate infection in only three cases (9.4%), at a mean follow-up of 55.1 months (SD 25 to 90). The mean postoperative Harris Hip Score and Hospital for Special Surgery knee score at the most recent follow-up were 81 (62 to 91) and 79 (56 to 89), respectively. One patient developed a fistula, and another presented with a local rash on an infected joint. The use of IA carbapenem delivered alongside one-stage revision effectively controlled Gram-negative infection and obtained acceptable clinical outcomes with few complications. Notably, first- and second-generation cephalosporins and penicillin should be administrated with caution, due to a high incidence of resistance.

Effects of Adding Morphine to Periarticular Infiltration Analgesia Combined with Single Dose Epidural Morphine in Total Knee Arthroplasty: A Randomized Controlled Study.

OBJECTIVE: Morphine plays an important role in postoperative analgesia after total knee arthroplasty (TKA). However, there are limited data that investigate the administration ways of morphine. To evaluate the efficacy and safety of adding morphine to periarticular infiltration analgesia (PIA) combined with single-dose epidural morphine for the patients undergoing TKA. METHODS: In total, 120 patients with knee osteoarthritis who underwent the primary TKA from April 2021 and March 2022 were randomized into three groups (a cocktail containing morphine with single-dose epidural morphine [Group A]; a cocktail containing morphine [Group B]; and a cocktail free of morphine [Group C]). The three groups were compared based on the Visual Analog Score at rest and during motion, requirement of tramadol, functional recovery including quadriceps strength and range of motion, and adverse events including nausea and vomiting and local and systemic adverse events. The repetitive measure analysis of variance and chi-square test among three groups were used to analyze the results. RESULTS: Analgesia strategy in Group A (0.4 ± 0.8, and 0.9 ± 1.0 points, respectively) significantly reduced rest pain at 6 and 12 h after surgery relative to Group B (1.6 ± 1.2, and 2.2 ± 1.4 points, respectively) (p < 0.001), and the analgesic effect of Group B was stronger than that of Group C (2.1 ± 0.9, and 2.6 ± 0.9 points, respectively) (p < 0.05). Rest pain at 24 h after surgery was significantly lower in Group A (2.5 ± 0.8 points) and B (1.9 ± 1.0 points) than in Group C (2.5 ± 0.8) (p < 0.05). Within 24 h after surgery, the requirements for tramadol in Group A (0.25 g) and Group B (0.35 g) were significantly lower than those in Group C (0.75 g) (p < 0.05). Within 4 days of surgery, the quadriceps strength in the three groups increased gradually, and no statistical significance was noted among the three groups (p > 0.05). From the second day to the fourth day after surgery, although the three groups showed no statistical difference in the range of motion, the result of Group C was inferior to that of the other two groups. There were no significant differences in the incidence of postoperative nausea and vomiting and metoclopramide consumption among the three groups (p > 0.05). CONCLUSION: PIA combined with single-dose epidural morphine effectively reduces early postoperative pain and tramadol requirement as well as few complications, which can become a safe and effective measure to improve postoperative pain after TKA.

[One-stage revision using intra-articular vancomycin infusion effectively treats chronic prosthetic joint infection caused by Enterococcal].

Objective: To investigate the clinical effects of one-stage revision combined with intra-articular infusion of vancomycin in the treatment of chronic prosthetic joint infection (PJI) caused by Enterococcal. Methods: From May 2013 to June 2020,the clinical data of 9 patients (2 males and 7 females) with chronic Enterococcal PJI treated with one-stage revision using intra-articular infusion of vancomycin at Department of Orthopaedics,First Affiliated Hospital of Xinjiang Medical University were retrospectively analyzed,including 8 hips and 1 knee.A total of 9 patients with age of (63.9±11.7)years (range:43 to 76 years) were included, and the body mass index was (23.6±4.3)kg/m2 (range:18 to 30 kg/m2).There were 6 cases with antibiotic history and 5 cases with sinus tract.The joint fluid,infected tissue around the prosthesis and ultrasonic shock fluid of the prosthesis were collected during operation for microbial culture identification and drug sensitivity test.After thorough debridement of the infected site and removal of the infected prosthesis,a new prosthesis was implanted,then the drainage tube in the operation area was placed.After surgery,vancomycin(1.0 g,q12 h) was combined with intra-articular vancomycin(0.5 g,qd) in monomicrobial PJI,and vancomycin(1.0 g,q12 h) was combined with intra-articular vancomycin (0.5 g,qd) and imipenem/meropenem (0.5 g,qd),and the interval between the two drugs was 12 hours in polymicrobial PJI.Hip and knee functions were evaluated by Harris Hip Score or Knee Society Score(KSS),respectively.The comparison of hip function scores before and after operation was performed by paired t-test. Results: All patients were followed up for (60±39)months(range:24 to 110 months).Two cases were infected with Enterococcus faecium and 7 cases were infected with Enterococcus faecalis.There were 7 cases of monomicrobial infection and 2 cases of polymicrobial infection.Erythromycin(5/9),tetracycline(4/9),ciprofloxacin and ß-lactam antibiotics(3/9) were the top three antibiotics in Enterococci resistance rate.The sensitive antibiotics for Enterococcal were vancomycin,linezolid and tigecycline.The average duration of intravenous antibiotics was (14±1)days (range:13 to 17 days),and the average duration of antibiotics in articular cavity was (15±2)days(range:11 to 20 days).Mean duration of oral antibiotic use after discharge was (2±1)months(range:1 to 3 months).One case of polymicrobial PJI treatment failed,with a failure rate of 1/9.At last follow-up,the Harris score of patients with hip PJI increased from (43±6)points to (84±6)points(t=-11.899, P<0.01). KSS score of knee function was improved from 33 point pre-operatively to 85 point post-operatively;overall function score was improved from 35 point pre-operatively to 80 point post-operatively.During the treatment,no formation of sinus tract of the hip joint caused by a catheter,skin necrosis at the knee puncture site or leakage of joint fluid;no complications such as deep vein thrombosis and pulmonary embolism occurred. Conclusions: One-stage revision combined with intra-articular infusion of vancomycin can achieve acceptable infection control rate and joint function in patients with chronic Enterococcus PJI.However,the treatment of polymicrobial PJI still needs to be further verified.

Diagnostic value of plasma fibrinogen in chronic periprosthetic infection / 中华骨科杂志

Objective:To investigate the diagnostic value of plasma fibrinogen (FIB) in chronic periprosthetic joint infection (PJI).Methods:A total of 470 patients who underwent revision hip and knee arthroplasty after primary hip and knee arthroplasty in the First Affiliated Hospital of Xinjiang Medical University from January 2013 to December 2021 were retrospectively analyzed. According to the diagnosis of the disease, 173 patients (112 hips and 61 knees) were divided into chronic PJI group, including 78 males and 96 females, aged 65 (53, 72) years; and 297 patients (216 hips and 81 knees) were divided into aseptic loosening group, including 108 males and 189 females, aged 63 (50, 72) years. The preoperative levels of FIB, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), D-dimer and platelet were compared between the two groups, and the sensitivity and specificity of the diagnosis of chronic PJI were calculated. Receiver operating characteristic (ROC) curves were used to determine the optimal cut-off values of FIB, CRP, ESR, platelet and D-dimer for the diagnosis of chronic PJI. The diagnostic efficacy of each indicator was analyzed by comparing the area under curve (AUC) and using a combined diagnostic test.Results:FIB, CRP, ESR, platelets and D-dimer in the chronic PJI group were 4.05 (3.52, 4.72) g/L, 19.5 (10.7, 40.0) mg/L, 50 (28, 60) mm/1 h, 270 (221, 351)×10 9 /L, 514 (261, 873) μg/L, respectively, which were higher than 3.25 (2.80, 3.63) g/L, 3.7 (2.0, 6.7) mg/L, 20 (12, 30) mm/1 h, 225 (182, 269)×10 9 /L, and 310 (167, 569) μg/L in sterile loosening group, with statistically significant differences ( P<0.05). The AUC of FIB, CRP, ESR, platelets and D-dimer in the diagnosis of chronic PJI were 0.78 (95% CI: 0.73, 0.82), 0.86 (95% CI: 0.82, 0.89), 0.80 (95% CI: 0.76, 0.85), 0.68 (95% CI: 0.63, 0.73), 0.64 (95% CI: 0.59, 0.69); the optimal cut-off values were 3.73 g/L, 9.64 mg/L, 39 mm/1 h, 280×10 9 /L, 624 μg/L; the sensitivity was 68%, 79%, 69%, 47%, 43%; the specificity was 81%, 85%, 85%, 81%, 79%, respectively. When CRP, ESR, FIB, platelets and D-dimer were combined sequentially to diagnose patients with chronic PJI, the sensitivity and specificity of the series test were 12.7% and 99.7%, and those of the parallel test were 100% and 37.3%. The combined diagnostic test showed that the maximum AUC of FIB combined with CRP was 0.85 (95% CI: 0.81, 0.89), with a sensitivity of 76% and a specificity of 89%. Conclusion:The clinical value of plasma FIB in the diagnosis of chronic PJI is not superior to that of CRP and ESR, but the combination of FIB and CRP can improve the specificity.

Gender differences in serological indicators for the diagnosis of chronic periprosthetic infections / 中华骨科杂志

Objective:To investigate the gender differences in serum C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), platelet (PLT), fibrinogen (FIB) and D-dimer for the diagnosis of chronic periprosthetic joint infection (PJI).Methods:A total of 470 patients who underwent revision arthroplasty in the Department of Joint Surgery, First Affiliated Hospital of Xinjiang Medical University from January 2013 to December 2021 were retrospectively analyzed. According to gender and diagnosis, they were divided into four groups: 78 cases of male chronic PJI, 108 cases of male aseptic loosening, 95 cases of female chronic PJI, and 189 cases of female aseptic loosening. The serological results of CRP, ESR, PLT, FIB and D-dimer were collected before operation. The receiver operating characteristics (ROC) curves were used to determine the optimal cut-off values of CRP, ESR, PLT, FIB and D-dimer for the diagnosis of chronic PJI in different genders, and to calculate their sensitivity and specificity. The diagnostic efficacy of the index was analyzed by comparing the area under curve (AUC) of different indicators.Results:The levels of ESR, PLT and D-dimer in the male chronic PJI group were 43 (20.0, 52.5) mm/1 h, 249×10 9 (204×10 9, 306×10 9) /L, 449 (219,833) μg/L, respectively, which were lower than those in the female group of 56 (40, 65) mm/1 h, 295×10 9 (228×10 9, 364×10 9) /L, and 645 (345, 1 157) μg/L, with statistically significant differences ( Z=-4.17, P<0.001; Z=-2.17, P=0.030; Z=-2.82, P=0.005). The AUC of CRP in the male chronic PJI group was 0.841, which was higher than the AUC of the other four indicators; CRP was combined with ESR, PLT, FIB and D-dimer to establish a joint prediction model for male chronic PJI. The ROC curve showed that the combination of CRP+FIB had a maximum AUC [0.849, 95% CI (0.79, 0.91)], sensitivity of 80% and specificity of 86%. The AUC of CRP in the female chronic PJI group was 0.866, which was higher than the AUC of the other four indices; CRP was combined with ESR, PLT, FIB and D-dimer to establish a combined prediction model for female chronic PJI. The ROC curve showed that the combination of CRP+PLT had the maximum AUC [0.883, 95% CI (0.84, 0.93)], sensitivity of 87% and specificity of 79%. Conclusion:Serologic indicators in patients with chronic PJI are gender-specific. CRP combined with FIB has the highest diagnostic value for the chronic PJI in males, while CRP combined with PLT has the highest diagnostic value for the chronic PJI in females.

Effective Treatment of Single-Stage Revision Using Intra-Articular Antibiotic Infusion for Polymicrobial Periprosthetic Joint Infection.

BACKGROUND: The treatment of polymicrobial periprosthetic joint infection (PJI) confronted distinct challenges. No reports have assessed the efficacy of local antibiotic delivery combined with 1-stage exchange in polymicrobial PJI. METHODS: Between January 2013 and December 2018, we retrospectively analyzed the data of 126 patients, including 19 polymicrobial PJIs and 107 monomicrobial PJIs, who underwent single-stage revision using intra-articular antibiotic infusion. The risk factors, microbiology, infection control rate, and clinical outcomes were compared between the 2 groups. RESULTS: Higher body mass index, presence of a sinus tract, and prior revisions were the risk factors for polymicrobial PJI. Isolation of Staphylococcus epidermidis, Streptococcus, Enterococcus, and Gram-negative pathogens was highly associated with polymicrobial PJI. Of the 19 polymicrobial PJIs, only 2 patients occurred infection recurrence, which is similar with the result of 6 of 107 patients in the monomicrobial PJI (P = .225). The Harris Hip Score of the polymicrobial group showed no difference from that of the monomicrobial group (78 vs 80; P = .181). Nevertheless, the polymicrobial group exhibited inferior Hospital for Special Surgery knee score relative to the monomicrobial group (77 vs 79; P = .017). CONCLUSION: With rational and targeted use of antibiotics, single-stage revision can effectively control polymicrobial infections, and achieve favorable outcomes similar to that in monomicrobial patients. However, this regimen is still needed to be further confirmed, especially in the infections with different microbial species simultaneously. Additionally, obese patients with a sinus tract and those who had prior revisions had a greater risk of polymicrobial PJI.

Total knee arthroplasty with the least-constrained implant possible for type II valgus knee > 20°: a 3-14 years' follow-up.

OBJECTIVE: To estimate the midterm outcome of primary total knee arthroplasty for severe valgus deformity using selective release of tight lateral structures and the least-constrained implant. METHODS: We performed total knee arthroplasty on 65 consecutive type II knees with valgus deformity> 20°. Surgery was done via a medial parapatellar approach. Conventional bone cutting was done with selective lateral soft tissue release, and the least-constrained total knee prosthesis possible was used. Posterior stabilized implants were employed in most knees, except for three knees that required the implantation of constrained condylar knee prostheses. The average duration of follow-up lasted for 10.5 years. RESULTS: Preoperatively, average valgus was 30.6°, and average range of motion was 43.7° (range, 0-80°). Postoperatively, average valgus was 7.3° and average range of motion was 110.6° (range, 80-130°). The lateral collateral ligament and iliotibial band were released in all knees, and release of the popliteus tendon was required in two knees. Stable flexion and extension gaps were achieved in most cases, except for two that had medial side instability. Follow-up showed that stability was maintained. CONCLUSIONS: This surgical technique combined selective lateral soft tissue release with use of the least-constrained implant possible and was effective for severe valgus deformities of the knee, with good clinical results.

Pulmonary hypertension could be a risk for deep vein thrombosis in lower extremities after joint replacement surgery.

OBJECTIVE: A background of Pulmonary Hypertension (PH) indicates a progressive elevation of pulmonary vascular resistance, leading to overfilling, elevation of venous pressure, congestion in various organs, and edema in the venous system. This study aimed to investigate whether PH is a risk factor for deep vein thrombosis (DVT) of the lower extremities after hip and knee replacement surgery. METHODS: A total of 238 patients who received joint replacement of lower extremities in our department of orthopedics from January 2009 to January 2012 were examined by echocardiography and Color Doppler flow imaging (CDFI) of the lower extremities. Based on pulmonary artery pressure (PAP), the patients were divided into a normal PAP group (n=214) and PH group (n=24). All the patients were re-examined by CDFI during post-operative care. RESULTS: Among the 238 patients, 18 had DVT in the lower extremities after the operation. DVT total incidence rate was 7.56% (18/238). In the PH group, 11 patients had DVT (45.83%, 11/24), but in the normal PAP group, only 7 had DVT (3.27%, 7/214). The incidence of DVT was significantly lower in the normal PAP group than in the PH group (P<0.01). In addition, there was a positive correlation between PAP and the incidence of DVT. CONCLUSION: PH could be a high-risk factor for the occurrence of DVT in patient's lower extremities after joint replacement surgeries.

Pulmonary hypertension could be a risk for deep vein thrombosis in lower extremities after joint replacement surgery

SUMMARY A background of Pulmonary Hypertension (PH) indicates a progressive elevation of pulmonary vascular resistance, leading to overfilling, elevation of venous pressure, congestion in various organs, and edema in the venous system. This study aimed to investigate whether PH is a risk factor for deep vein thrombosis (DVT) of the lower extremities after hip and knee replacement surgery. METHODS A total of 238 patients who received joint replacement of lower extremities in our department of orthopedics from January 2009 to January 2012 were examined by echocardiography and Color Doppler flow imaging (CDFI) of the lower extremities. Based on pulmonary artery pressure (PAP), the patients were divided into a normal PAP group (n=214) and PH group (n=24). All the patients were re-examined by CDFI during post-operative care. RESULTS Among the 238 patients, 18 had DVT in the lower extremities after the operation. DVT total incidence rate was 7.56% (18/238). In the PH group, 11 patients had DVT (45.83%, 11/24), but in the normal PAP group, only 7 had DVT (3.27%, 7/214). The incidence of DVT was significantly lower in the normal PAP group than in the PH group (P<0.01). In addition, there was a positive correlation between PAP and the incidence of DVT. CONCLUSION PH could be a high-risk factor for the occurrence of DVT in patient's lower extremities after joint replacement surgeries.

RESUMO OBJETIVO A hipertensão pulmonar (HP) indica elevação progressiva da resistência vascular pulmonar, levando ao excesso de enchimento, elevação da pressão venosa, congestão em vários órgãos e edema no sistema venoso. Este estudo teve como objetivo investigar se a HP é um fator de risco para trombose venosa profunda (TVP) das extremidades inferiores após cirurgia de prótese de quadril e joelho. MÉTODOS Um total de 238 pacientes que receberam a substituição da articulação das extremidades inferiores em nosso departamento de ortopedia de janeiro de 2009 a junho de 2012 foi examinado por ecocardiograma e fluxo de imagem Doppler colorido (CDFI) dos membros inferiores. De acordo com a pressão arterial pulmonar (PAP), os pacientes foram divididos em grupo PAP normal (n=214) e grupo PH (n=24). Todos os pacientes foram reexaminados por CDFI durante os cuidados pós-operatórios. RESULTADOS Entre os 238 pacientes, 18 pacientes tiveram TVP nas extremidades inferiores após a operação. A taxa de incidência total de TVP foi de 7,56% (18/238). No grupo PH, 11 pacientes tiveram TVP (45,83%, 11/24), mas no grupo PAP normal, apenas sete pacientes tiveram TVP (3,27%, 7/214). A incidência de TVP foi significativamente menor no grupo PAP normal do que no grupo PH (P<0,01). Além disso, houve uma correlação positiva entre a PAP e a incidência de TVP. CONCLUSÃO A HP poderia ser um fator de alto risco para a ocorrência de TVP nas extremidades inferiores do paciente após cirurgias de substituição articular.

Total knee arthroplasty for severe valgus knee deformity / 中华骨科杂志

Objective To investigate the surgical methods and clinical effects of total knee arthroplasty (TKA) in patients with severe valgus knee deformity.Methods From January 2007 to December 2012,22 patients with 23 severe valgus knee deformity underwent TKA by means of medial parapatellar approach,standard osteotomy and only lateral soft tissue release with posterior stabilized implants were retrospectively analyzed.They were 7 males and 15 females,aged from 41 to 78 years,with an average age of 65 years.Tibiofemoral angle (angle between the femur and tibia anatomic axis) was 22°-50°,with an average of 34.6±2.4°.Among them,17 cases were osteoarthritis,5 cases were rheumatoid arthritis,3 cases complicated with patella dislocations,1 case complicated with medial instability,3 cases of 4 knees complicated with flexion contracture.Posterior stabilized prosthesis were used in 21 cases of 22 knees,constrained prosthesis were used in 1 case of 1 knee,5 cases accepted intraoperative patellar replacement.Clinical and radiographic evaluations including range of motion (ROM),the Hospital for Special Surgery (HSS)knee score and the tibial and femur angle (T-F angle) were performed at follow-up.Results The duration of follow-up averaged 30.5 months.The average HSS score improved from 19.6±4.7 points preoperatively to 89.7±3.6 points at the time of the last follow up.The average ROM improved from 43.7°-±5.8° preoperatively to 110.6°±7.5°.The average T-F angle was 8.6°±0.8°.We had 5 patella replacements,2 medial instability cured by using articular branches,2 palsies of nervus peroneus communis recovering after 3 months.No complications such as infection,DVT,or component loosening.Conclusion The techniques of medial parapatellar approach,standard osteotomy and only lateral soft tissue release with posterior stabilized implants can deal with a severe valgus knee deformity very successfully in patients undergoing primary total knee arthroplasty,and provide excellent results.